Gastroenterology

Abdominal pain and related symptoms

Pain even on an empty stomach, pain that does not settle with medicine, black stools. A gastroscopy is needed urgently to check for a bleeding lesion. If it is a gastric ulcer, we treat it with oral medication and test for H. pylori. If there is active bleeding, haemostasis and admission to hospital are required. If the cause is malignant, we refer you to a facility that can treat it.

Pain after eating, a feeling of food catching in the chest, heaviness, acid rising, heartburn. Here too we perform a gastroscopy to check that nothing malignant is present. If it is reflux oesophagitis, we treat it with oral medication.

No symptoms at all. Regular endoscopic screening still matters for catching cancer early. This counts as screening, so it falls outside insurance. Barium is a reasonable option, but its diagnostic accuracy is around 60–80%; with endoscopy it is over 90%.

Minato City residents aged 50 and over are mailed a gastroscopy voucher once every two years, and the ward covers the cost of the examination. Sedation is not available under the voucher.

Helicobacter pylori: consultation, testing and eradication

If a health check has shown you to be H. pylori antibody positive, or a barium examination has produced a report calling for further investigation, bring the report and we will perform a gastroduodenal endoscopy. That pathway is covered by insurance. Broadly, we confirm that there is no gastric cancer or other disease; if gastritis is present, eradication is indicated, and we explain why it matters — the risk of gastric cancer, gastric ulcer and duodenal ulcer if it is left untreated. We then prescribe the course of medication. Afterwards a follow-up test is essential, chiefly because eradication succeeds in about 80% of cases, not 100%.

Treatment or consultation without a gastroscopy is self-pay.

Antibody testing on its own (blood or urine) is treated as screening rather than treatment, so it is not covered by insurance:

Helicobacter care is a relatively new field. Insurance cover for treating chronic gastritis began in Japan in 2013 — the first country in the world to do so — and the rules and procedures can be hard to follow, which is why we recommend being seen by a certified physician. The director is a Helicobacter pylori Infectious Disease Certified Doctor.

Gastric cancer

Gastric cancer remains a major disease in Japan: as of 2019 it was the third leading cause of cancer death across men and women combined. It was once put down to diet, but since H. pylori was identified the main cause is understood to be chronic gastritis from H. pylori infection. Five-year survival is below 50% in many countries; in Japan a culture of early detection has long been established. For several years now Tokyo's screening programme has included gastroscopy, which is more accurate than barium, so screening can be expected to do more than before. What matters is actually attending it.

Even when chronic or atrophic gastritis improves after eradication, the risk of gastric cancer does not fall to zero — a certain number of cancers do occur after eradication. Regular screening is still needed for something like 5 to 10 years afterwards (this is still being studied). Found early, some cancers can be treated endoscopically, without open surgery.

Gastric ulcer

Even with today's medication we still see several cases a year. If over-the-counter medicine has not helped, or a prescription from another hospital has not helped, and you have abdominal pain — before meals, and at night — black stools, or light-headedness when walking or climbing stairs, a gastroscopy is needed promptly. If an ulcer or gastritis is found, we test for H. pylori as well.

The causes vary — overwork severe enough to stop you sleeping, illness or loss in the family — and H. pylori infection is one of the major ones. Treatment is not a few days of over-the-counter medicine: it is a prescribed drug taken for six to eight weeks, followed by a second endoscopy and a tissue examination to confirm healing and to make sure it was not a cancer masquerading as an ulcer.

Positive faecal occult blood, bleeding, and changes in bowel habit

A positive faecal occult blood result at screening, blood in the stool, rectal bleeding, discomfort on passing stool, a change in bowel habit, diarrhoea lasting more than two weeks, or chronic abdominal pain all call for a colonoscopy and anoscopy. Where there is bleeding we do this as soon as we can. Even when the bleeding is coming from haemorrhoids, a colonoscopy is still needed — anoscopy alone cannot examine the colon.

Facilities offering internal medicine alone frequently cannot examine haemorrhoids, so within general medicine please go to a proctology or gastrointestinal surgery department.

What matters in investigating bleeding is establishing the cause — ruling out colorectal cancer, identifying where the blood is coming from, and judging whether further treatment is needed or observation is enough. What we see here includes ischaemic colitis, ulcerative colitis, large colorectal polyps, Crohn's disease, colonic diverticulosis, infectious colitis and colorectal cancer.

Colorectal polyps

Some colorectal polyps are precancerous lesions, known to turn malignant as they grow. So what counts in a colonoscopy is how well polyps are found. For that reason we spend enough time looking — over 10 minutes, since under six minutes has been reported to miss a great deal — and then judge whether what we find should be removed.

At roughly 5 mm and above we assess colour and shape and apply NBI, a special light that brings out the pattern of the blood vessels, to decide whether resection is needed. We carry out examinations on that basis. Where endoscopic resection does follow, there is a real risk of bleeding and abdominal pain, so we ask you to stay close to home for a week and advise you on resting the bowel and the body.

Inflammatory bowel disease (IBD)

The director is a designated intractable disease physician (難病指定医).

We treat ulcerative colitis (UC) and Crohn's disease (CD). The causes are still being investigated, and these are among the conditions that are becoming more common. Mild to moderate disease that does not require admission is now something that can be managed at a clinic.

Ulcerative colitis presents with repeated bloody stools, mucus and blood, diarrhoea, abdominal pain and frequent, urgent need to open the bowels — though sometimes the only sign is a positive faecal occult blood test. It is seen in young people and also from middle age onwards.

Crohn's disease can add weight loss and fever to those symptoms, or present only as anal disease such as a fistula or fissure. Diagnosis is made chiefly by colonoscopy; for Crohn's disease it is appropriate to look at the whole digestive tract.

There are many treatments — oral and injectable — including Pentasa suppositories, Asacol, Lialda and steroid preparations. We decide on the approach together with you, taking your symptoms and your circumstances into account.

Treatment is something you stay on so that the disease does not flare again. As the ten-year mark approaches, malignant lesions become more likely, which makes an annual endoscopy very important.

Functional dyspepsia (FD)

Chronic pain in the stomach after eating, a heavy feeling in the stomach. The triggers are often not straightforward: abnormal gastroduodenal motility, heightened sensitivity to fat and to stomach acid, and beyond that stress, genetics and gut hormones.

Before treating it, we confirm with a gastroduodenal endoscopy that there is no gastric ulcer or gastric cancer. If H. pylori infection is present, we eradicate it. Treatment includes Kampo herbal medicine and Acofide. Beyond medication, some people are reassured simply by learning that the endoscopy found nothing wrong, and some are not able to eat with enough time or ease — so we advise on that side of things too. Most people improve with this.

Irritable bowel syndrome (IBS)

Stress can be bound up with abdominal discomfort, diarrhoea and constipation. That the gut is connected to the brain is established psychologically, and is known as the brain–gut interaction. Something that settles in a few days or weeks does not fall under this diagnosis; it applies to a course lasting at least six months. Diagnosis is usually made from the history, with colonoscopy as a supporting examination. There are a number of medications, and responses vary widely from person to person, so we fit the treatment to your own habits and follow how it goes.

Faecal occult blood testing

This is the test generally used for colorectal cancer screening; here the result comes back within minutes of the sample being taken.

Digital rectal examination — examination with a finger — is the single most important examination for rectal cancer.

Investigating blood in the stool moves through anoscopy, proctoscopy, sigmoidoscopy and then full colonoscopy, going as far as needed and discussed with you until the diagnosis is clear. Proctoscopy and sigmoidoscopy need only an enema as preparation.